By submitting a story to Summit Orthopedics, LLC (Summit), I hereby acknowledge that I am disclosing any information therein on a public media, including personally identifiable health information (PHI) and grant permission for Summit to use the content in its entirety or to edit, modify or adapt it as Summit deems warranted. I am also granting permission for Summit to distribute or publish my story on its Intranet or Internet websites or through any other printed media, social media, presentations, radio, television, mailings, exhibits, billboards, posters, press releases, and webcasts, including the use of my name, age and community. I agree that Summit dos not need my approval of any finished product or any specific use of my story or image. I agree that Summit may regard this authorization as a consent under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) for further disclosure of my PHI, as may be included in my story.
This authorization for use is effective from this date, and the story may be used or reused indefinitely by Summit in the future. I agree to be contacted by the media regarding my story and to be a spokesperson on behalf of Summit related to the substance of my story. I understand that no payment will be made to me for the use of these materials, and I agree not to seek any form of compensation from Summit related to the use of my story. I understand that I can revoke my consent at any time for future uses of my story, but I understand that any form of media which has already been published, planned or to which Summit has committed will still proceed.
I waive any and all claims against Summit arising from the use of my story in any material selected by Summit or related to any blurring, cropping, distortion, alteration or use in composite form that may occur in the creation and processing of the media. This waiver includes any claims for libel or breach of privacy.
I hereby certify that I am at least 18 years of age, that the story is entirely factual and that I am the individual represented by the story. I understand that, if it is determined that I have misrepresented either the facts or my identity, Summit may pursue legal action against me for such fraudulent misrepresentation. I hereby indemnify and will defend Summit from and against any and all liability or claims of any kind by a third party connected to Summit’s reliance upon and use of the story I have submitted.